Reprinted from the Globe and Mail (Toronto, Canada), February 22, 2003
An HIV What If

“How does one explain all the HIV-positive babies whose biological mothers test negative? Why does the spread of HIV not conform with the spread of other sexually transmitted infections?”
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[Although written from a conventional perspective and with misguided ideas about the accuracy of HIV tests, the following editorial aptly highlights what doesn’t add up about “HIV transmission” in Africa. Apparently the author is unaware that no HIV tests are actually able to diagnose infection with HIV or that the antibodies formed in response to more than 60 different conditions—including pregnancy, immunizations, malnutrition, exposure to TB, malaria and many common diseases—can cause positive reactions on the supposedly specific HIV antibody tests.]

People who poke holes in the received wisdom may be an irritant, but their skepticism can be valuable.

So it may be with a study released this week in the International Journal of STD and AIDS, a peer-reviewed publication of Britain's Royal Society of Medicine. Six American and two European researchers, two of them medical doctors, ask an impertinent question about the rapid spread of HIV/AIDS in sub-Saharan Africa: Why are so many AIDS experts so sure that the bulk of the virus's transmission there is through heterosexual sex?

Certainly HIV can be transmitted that way; safe sex is crucial to block its spread. But the risk of infection is even higher through contaminated needles, including needles used in medical care. The researchers say the risk of contracting HIV through penile-vaginal exposure is one in 1,000, against one in 100 for illicit-drug injection with dirty needles and one in 30 for medical injections with dirty needles. (They do not include figures for anal intercourse.)

They found it hard to believe that the rapid speed of infection in many African countries could be accounted for by sex. They could find no documented explanation of the 1988 estimate by the World Health Organization (WHO) that 80 per cent of HIV infections in Africa resulted from heterosexual transmission -- a figure that quickly became part of the lore and has been inflated to 90 per cent in some reports.

So they read every peer-reviewed study they could find on HIV/AIDS field work in Africa between 1984 and 1988. They concluded that the extent of HIV transmission through contaminated medical equipment has been drastically understated. They even suggest that sexual transmission of HIV accounts for only one-third of HIV cases.

The study's authors are perplexed by the anomalies they found. How does one explain all the HIV-positive babies whose biological mothers test negative? Why does the spread of HIV not conform with the spread of other sexually transmitted infections? In Zimbabwe in the 1990s, HIV increased by 12 percent a year while sexually transmitted diseases as a whole fell by 25 percent and condom use rose among those groups considered at highest risk of infection -- prostitutes, truck drivers, miners, young people.

Why does the capital of Cameroon, Yaoundé, have a high rate of risky social behavior, yet "low and stable" rates of HIV infection?

The authors have, as they expected, encountered criticism, not least because the studies they reviewed are two decades old. And certainly overreaction would be as dangerous as no reaction; the last thing anyone should want is to compromise programs that encourage safe sex.

All the authors ask, however, is that the same degree of attention focused on heterosexual sex be given to the safety of medical treatment in African countries where HIV has grown into a scourge of tragic proportions. One of the authors, David Gisselquist, has been invited to a March 13-14 meeting of WHO and the United Nations agency UNAIDS in Geneva to make his case.